standard operating procedures manual 8 - compare, save

MARKETPLACE ASSISTER TOOLKIT

Standard Operating Procedures Manual for Assisters in the Individual Federally-facilitated Marketplaces SOP 8—COMPARE, SAVE, & SELECT HEALTH PLANS

Version 6.0 December 2020. This information is intended only for the use of entities and individuals certified to serve as Navigators or certified application counselors in a Federally-facilitated Marketplace. The terms “Federally-facilitated Marketplace” and “FFM,” as used in this document, include FFMs where the state performs plan management functions. Some information in this manual may also be of interest to individuals helping consumers in State-based Marketplaces and State-based Marketplaces using the Federal Platform. This document is intended only as a summary of legal requirements and to provide operational information and does not itself create any legal rights or obligations. All legal requirements are fully stated in the applicable statutes and regulations. The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law. This material was printed, published, or produced and disseminated at U.S. taxpayer expense.

This information is intended only for the use of entities and individuals certified to serve as Navigators or certified application counselors in a Federally-facilitated Marketplace. The terms “Federally-facilitated Marketplace” and “FFM,” as used in this document, include FFMs where the state performs plan management functions. Some information in this manual may also be of interest to individuals helping consumers in State-based Marketplaces and State-based Marketplaces using the Federal Platform. i

Table of Contents

SOP 8 – COMPARE, SAVE, & SELECT HEALTH PLANS.............................................................................1 A. Introduction .................................................................................................................... 1 B. Procedures ...................................................................................................................... 2 C. Next Steps ..................................................................................................................... 16 Appendix A: Frequently Asked Questions (FAQs) ................................................................... 17 Appendix B: Support Resources .............................................................................................. 19

This information is intended only for the use of entities and individuals certified to serve as Navigators or certified application counselors in a Federally-facilitated Marketplace. The terms “Federally-facilitated Marketplace” and “FFM,” as used in this document, include FFMs where the state performs plan management functions. Some information in this manual may also be of interest to individuals helping consumers in State-based Marketplaces and State-based Marketplaces using the Federal Platform. ii

List of Exhibits

Exhibit 1 – Setting the Amount of Advance Payments of the Premium Tax Credit Screenshot .................. 2 Exhibit 2 – Deciding How Much APTC to Apply to Monthly Premiums Screenshot ..................................... 3 Exhibit 3 – Tax Consequences for Chosen Amount of APTC to Apply to Monthly Premiums ...................... 4 Exhibit 4 – Filtering Options ......................................................................................................................... 6 Exhibit 5 – Filtering Options Screenshot ...................................................................................................... 7 Exhibit 6 – Select a QHP for Plan Comparison Screenshot ........................................................................... 8 Exhibit 7 – Side-by-Side Plan Comparison Screenshot ................................................................................. 9 Exhibit 8 – Warning Message Screenshot .................................................................................................. 11 Exhibit 9 – Confirm Health Plan Selection Screenshot ............................................................................... 12 Exhibit 10 – Your Selected Plan Screenshot ............................................................................................... 13 Exhibit 11 – Confirming Dental Plan Selection Screenshot ........................................................................ 14 Exhibit 12 – Confirm Your Plan Choices Screenshot................................................................................... 15 Exhibit 13 – External Resources ................................................................................................................. 19

This information is intended only for the use of entities and individuals certified to serve as Navigators or certified application counselors in a Federally-facilitated Marketplace. The terms “Federally-facilitated Marketplace” and “FFM,” as used in this document, include FFMs where the state performs plan management functions. Some information in this manual may also be of interest to individuals helping consumers in State-based Marketplaces and State-based Marketplaces using the Federal Platform. 1

SOP 8 – Compare, Save, & Select Health Plans

A. Introduction

The Marketplace allows consumers to compare available Marketplace health and dental plans, including estimated premiums and other health care costs. Before consumers begin a Marketplace application, the Savings Estimator Tool and the See Plans and Prices Tool at HealthCare.gov can provide them with a quick view of income levels that qualify for savings and help them learn about the features and costs of different Marketplace plans in their area.

Consumers without a Marketplace account may:

• View key plan details, such as premiums and deductibles, as well as an estimate of any advance payments of the premium tax credit (APTC) and extra savings on out-of-pocket costs (also called “cost-sharing reductions” or “CSRs”) for which they may be eligible.

• Estimate their total costs during a plan's coverage year based on how much health care they might use.

• View, download, or print a plan’s Summary of Benefits and Coverage (SBC).

• View a plan’s provider directory and list of covered drugs.

• View quality ratings of health plans.

If consumers choose to compare plans without creating an online account and submitting an application, explain that the health plan and cost options displayed are only estimates based on their responses to a few general questions. If consumers are interested in more detailed information about their available health coverage options, including their eligibility for other coverage programs [i.e., Medicaid and the Children’s Health Insurance Program (CHIP)] or options to lower their costs (i.e., APTC and CSRs), encourage them to create an online account and complete an eligibility application.

Standard Operating Procedure (SOP) 8 provides guidance on how to assist consumers who are eligible to enroll in a Marketplace health plan as they compare plans and make a final qualified health plan (QHP) selection.

• To help consumers create an account, refer to SOP 3 – Create an Account.

• To help consumers submit an eligibility application, refer to SOP 5 – Apply for Health Coverage.

https://www.healthcare.gov/lower-costs/

https://www.healthcare.gov/see-plans/#/



B. Procedures

1. Selecting Advance Payments of the Premium Tax Credit

After consumers submit a Marketplace application and receive an eligibility determination notice, if applicable, HealthCare.gov will prompt eligible consumers to set the amount of APTC they want to apply to their monthly premiums before viewing their plan options, as shown in Exhibit 1.

Exhibit 1 – Setting the Amount of Advance Payments of the Premium Tax Credit Screenshot

Step 1. Explain to consumers that if they’re eligible for APTC, they will see different options on choosing how much of their APTC they want to use to lower their monthly premiums, as shown in Exhibit 2. Consumers can choose to apply all, some, or none of the amount to lower their monthly premiums, in most cases. The options affect the consumers’ monthly premium costs and, potentially, their tax liability when they file their federal income tax returns. After reviewing, the consumers will select their preferred amount of APTC and select Save & Continue.



Exhibit 2 – Deciding How Much APTC to Apply to Monthly Premiums Screenshot

Step 2. When consumers view and compare Marketplace plans, the Marketplace will reduce the premium amounts displayed according to the amount of APTC they select. Inform consumers that at any time before enrolling in a plan, consumers may adjust the amount of APTC that they would like to use. Consumers will also be able to change the amount after enrolling in a plan, but when that change takes effect will depend on the calendar date on which the change is made.

Step 3. Explain to consumers that the amount of APTC that they would like to apply to their monthly premiums may have tax consequences. Exhibit 3 provides an explanation of the tax consequences consumers might encounter.



Exhibit 3 – Tax Consequences for Chosen Amount of APTC to Apply to Monthly Premiums

Scenario Tax Consequence

• Applies less APTC than the maximum forwhich they are eligible, and/or

• Actual household income ends up beingless than the amount they projected forthe tax year, and/or

• Household size increases.

Consumers’ tax liability might decrease, and this might increase their tax refund or reduce the amount of tax they would otherwise owe at tax time if the premium tax credit (PTC) for which they are eligible at tax time exceeds the APTC that was paid on their behalf during the year.

• Applies the maximum APTC for which theyare eligible, and/or

• Actual household income ends up beingmore than the amount they projected forthe tax year, and/or

• Household size decreases.

Consumers’ tax liability might increase, and this might reduce their refund or increase the tax they would otherwise owe at tax time if the PTC for which they are eligible at tax time is less than the APTC that was paid on their behalf during the year.

Step 4. Remind consumers that they are required to report changes to their information, such as income and household-related changes, other coverage, and demographic information to the Marketplace within 30 days of the change, and should do so as soon as possible. These changes may affect the amount of APTC and extra savings (i.e., CSRs) for which they are eligible.

2. Comparing Marketplace Plans

This section provides information on different criteria (e.g., cost, benefits covered) consumers may want to use to compare and evaluate Marketplace health plans. While you can help consumers compare plans based on the applicant’s and their family members’ unique coverage needs, you should never advise consumers to choose specific plans.

Step 1. Explain to consumers the factors that might affect their available Marketplace plan options and costs:

a. Place of residence

b. Age

c. Family size

d. Tobacco use

e. Eligibility for APTC and CSRs

Step 2. Assist consumers with comparing health plans using the table that summarizes plans by:

a. Plan category (Silver, Gold, etc.)

b. Displaying premium ranges (after application of APTC, if applicable)



c. Extra savings they may be eligible for (e.g., if CSRs, how that impacts deductibles and out-of-pocketexpenses in certain plans)

The plan results page provides consumers with summary information about individual plans, including the cost of premiums.

Step 3. Assist consumers with filtering and sorting Marketplace plans to find plans that best meet their needs and budget. Encourage consumers to consider different aspects of coverage, including costs (premiums, copayments, coinsurance, deductibles, out-of-pocket maximums, etc.), coverage (such as services, devices, and medications), and provider network to determine whether preferred medical providers are covered in the plan’s network. (Consumers may be able to visit providers who don’t contract with their plan, but visiting an in-network provider usually means they’ll have lower out-of-pocket costs.) Consumers should review all aspects that are important to them before choosing and enrolling in a plan.

a. Estimates: The Marketplace can provide consumers with an estimate for their total health plan costsfor the year based on how much medical care the consumers think they will use (low, medium, orhigh). This can help consumers consider and compare different types of health insurance and healthcare costs beyond just monthly premiums. It is important to remind the consumer that these areestimates only and that actual costs to the consumer can vary based on actual health care usethroughout the year.

b. Filtering/Sorting: The Marketplace initially sorts plans from the lowest to highest premium amount,and consumers can choose to sort plans by deductibles instead. Consumers may filter plans tonarrow their selection and view plans by other criteria, such as by insurance company, price ranges,maximum out-of-pocket costs, and other features. Exhibit 4 specifies the various filtering optionsavailable to consumers for customizing their Marketplace plan list and provides examples of whento use each filtering option. It may be helpful to review the chart with consumers and identify thefiltering options that are most important to them. Exhibit 5 displays the screen on which consumerscan set filtering options.



Exhibit 4 – Filtering Options

Filtering Option Search Priority Description of Filtering Options

Health Plan Categories

Consumers who want to view only those plans that can be expected to cover, on average, 70 percent or more of their health care costs (i.e., a Silver-level plan or higher).

• Assignment of plan categories: Bronze, Silver, Gold,Platinum, and Catastrophic (like a Platinum categoryplan, on average, will cover a higher percentage ofcosts of care than a Bronze category plan, but willgenerally have a higher premium).

• You should remind consumers eligible for income-based CSRs that they can only take advantage ofthose extra savings if they enroll in a Silver plan.

Monthly Premium Consumers who are concerned about monthly premium costs.

• Price range that consumers pay monthly for theirMarketplace plan.

Maximum Yearly Deductible

Consumers who want to view only those plans that have a deductible amount within a certain range.

• The required amount consumers must pay beforetheir health coverage begins to cover most healthcare costs.

Health Plan Types Consumers who are concerned with flexibility of access to providers inside and outside of a network or are interested in coverage in multiple states.

• Types of provider access, such as HealthMaintenance Organization (HMO), PreferredProvider Organization (PPO), Point of Service (POS),and multi-state or national provider networks.

Health Savings Account (HSA)- Eligible Plans

Consumers who are considering enrolling in a high deductible health plan (HDHP), which is eligible for a health savings account (HSA).

• Tax-advantaged medical savings account available toconsumers who are enrolled in an HSA-eligibleHDHP. Funds that the consumer contributes to theaccount are not subject to federal income tax at thetime of deposit.

Doctors & Facilities Consumers who have doctors or facilities they like and want to see plans that include them.

• Enter the doctors’ names and medical facilities tocheck whether they are in a plan’s network.

Prescription Drugs Consumers who have medications they take on a regular basis.

• Enter medications to check whether they arecovered by a plan, including whether the brandand/or generic version of the drug is covered.

• Consumers should also review the details for anyplans they’re interested in and compare costinformation for each plan’s “formulary” (list ofcovered drugs) to understand how much eachprescription would cost through different plans.

Insurance Companies

Consumers who want to view only health plans from a specific insurance company.

• Select an insurance company to see just those plansat a time.

Medical Management Program

Consumers who have specific conditions, such as obesity, back pain, and diabetes.

• Select from a list of medical management programsto see which plans which offer these services.

Search by Plan ID Consumers who already know which plan they want can search for it by the plan number.

• Enter the plan number to find a preferred planquickly.



Exhibit 5 – Filtering Options Screenshot

c. Dental coverage preference as a part of their health plan: Under the Patient Protection andAffordable Care Act, dental insurance is treated differently for adults and children 18 and under.Dental coverage for children is a category of essential health benefits (EHB). Dental coverage isincluded in some Marketplace health plans. Consumers can see which plans include dental coveragewhen they compare them. If a health plan includes dental, the premium covers both health anddental coverage. For more information on dental coverage, refer to Section 5 below.

Step 4. Explain to consumers that once they identify potential health plans that meet their specifications, consumers may compare up to three plans side by side to review cost and benefit information across a few plans at the same time.

a. To select plans for comparison, consumers can select the “Compare” box listed below the qualityrating in the top right. Next, select the Compare plans button at the top left of the page. Refer toExhibit 6 for an illustration of this process. Note that consumers can select and compare up to threeplans at one time. Consumers can also hover their cursor over the “i” icons for explanations aboutthe different information displayed.



Exhibit 6 – Select a QHP for Plan Comparison Screenshot

b. The side-by-side comparison, shown in Exhibit 7, allows consumers to compare monthly premiums,annual deductibles, medical and prescription drug benefits, and other key information.



Exhibit 7 – Side-by-Side Plan Comparison Screenshot

Step 5. Remind consumers to make sure their doctors or other health providers are in-network for the specific plan they are considering before they enroll. Also remind consumers to enter the information for any medications they take to verify if the medications are covered. The best way for consumers to ensure a provider participates in the specific plan they are selecting is for consumers to call both their doctor or provider and the insurance company to make sure the doctor or provider is in the relevant network. If consumers want a plan that includes their health provider(s) or specific prescription drugs in the plan’s



list of covered drugs, direct them to the following external resources for additional information about the Marketplace health plans, including:

a. Plan websites.

b. Individual plan provider directories.

c. SBCs. Consumers can find this information by selecting the “Details” link for the plan atHealthCare.gov.

3. Selecting a Marketplace Health Plan

Explain to consumers that after they review and compare their available health plan options, they may select plans to enroll in for themselves and any household members included on their application. (Consumers can also select different health plans for different people on a single application by creating different enrollment groups in the enrollment section of HealthCare.gov after submitting their application.) After selecting Enroll, different warnings may appear that indicate the consumer may have missed the opportunity to participate in a plan with extra savings from CSRs (for example, if the consumer selected a plan that is not a Silver-level plan) or that they selected a plan covering a child that does not provide child dental coverage. One example of this warning message is shown in Exhibit 8. Consumers will be asked to confirm their plan selection, as shown in Exhibit 9.

https://www.healthcare.gov/health-care-law-protections/summary-of-benefits-and-coverage/



Exhibit 8 – Warning Message Screenshot



Exhibit 9 – Confirm Health Plan Selection Screenshot

4. Saving Plans

Inform consumers that if they would like to review plans at a later time, they can log into their account to resume enrollment. If consumers previously selected a health plan to enroll in but did not finalize their enrollment, their plan will appear at the top of the screen above the other health plan choices on the “Pick a health plan” screen, as shown in Exhibit 10.



Exhibit 10 – Your Selected Plan Screenshot

5. Dental Coverage

Step 1. Explain that some medical plans include child and/or adult dental coverage. If consumers want dentalcoverage, they can select a medical plan that includes dental coverage or select a stand-alone (separate) dental plan.1 If no separate dental plan is desired, consumers can skip directly to the “Review and Confirm” task. If consumers wish to select a stand-alone dental plan, proceed to Step 2.

Step 2. Help consumers indicate if they are interested in enrolling in a separate dental plan. The process will proceed similarly to the medical plan compare and selection process. Once available dental plans appear, you can assist consumers with enrolling in a dental plan.

a. A consumer must enroll in a medical plan in order to enroll in a stand-alone dental plan through theHealth Insurance Marketplace®.2

b. Consumers can enroll in a stand-alone dental plan through the Marketplace even after they havealready enrolled in health coverage as long as it is still Open Enrollment or if they have a SpecialEnrollment Period (SEP). To do so, consumers need to return to the Marketplace, re-select theirMarketplace health plan, and then select a dental plan at the same time to add a dental plan.Assisters helping consumers in this situation can remind consumers that the coverage effective date

1Note that because adult dental coverage is not an essential health benefit, APTC cannot be used to pay any portion of a premium attributable to coverage of adult dental benefits. 2Health Insurance Marketplace® is a registered service mark of the Department of Health & Human Services.



of their dental plan will depend on the date that they enroll in the dental plan, not the date when they originally selected health coverage.

Step 3. Inform consumers that once they select Enroll, a confirmation window will appear. It will provide a summary of the plan selection, and if the consumer agrees, they will select Select this plan, as shown in Exhibit 11.

Exhibit 11 – Confirming Dental Plan Selection Screenshot

6. Review and Confirm

Step 1. Explain to consumers that after confirming their dental plan, they will be directed to the “Confirm yourplan choices” page where the consumer can see a summary of the plan(s) they selected and must select Continue to provide a final approval to enroll in the plans. An example of this summary and enrollment appears in Exhibit 12.



Exhibit 12 – Confirm Your Plan Choices Screenshot

Step 2. Inform consumers that on the “Read & agree with this statement to continue” page, consumers must attest to their understanding that they may no longer be eligible for APTC if they experience certain life changes or are found eligible for other qualifying health coverage, like most Medicaid, CHIP, or job-based coverage, and that the household tax filer may have to pay back some or all APTC used if the consumer fails to take appropriate action.

Step 3. Explain to consumers that they will accept eligibility for APTC (if applicable) by agreeing to file a federal income tax return in the upcoming year for the current tax year and attesting to the filing of a joint income tax return with their spouse by the end of the current tax year (if married). Consumers are also attesting that no one else can claim them as a dependent for the current tax year on a federal income tax return. After selecting “I agree with the above statements,” the consumer needs to enter their full name and select Continue.



C. Next Steps

1. If consumers wish to pay their health plan premium, proceed to SOP 9 – Pay Health Plan Premium.

2. If consumers have questions on reconciling any APTC received when filing a federal income tax return,proceed to SOP 12 – Reporting Minimum Essential Coverage and Reconciling Advance Payments of thePremium Tax Credit.

3. For more help answering consumers’ specific questions, refer to Appendix A: Frequently AskedQuestions (FAQs).



Appendix A: Frequently Asked Questions (FAQs)

The FAQs below are designed to help assisters answers consumers’ specific questions on comparing and selecting plans through the Individual Marketplace.

FAQ 1. How do I view the different plans and compare them?

o Answer: You can view and compare plans by logging into your HealthCare.gov account or usingthe See Plans and Prices tool at HealthCare.gov before you create an account.

FAQ 2. Can I browse health plans in the Marketplace without creating an account?

o Answer: Yes, you can browse and compare plans at the HealthCare.gov website. However, youcannot see the exact amounts of what your costs would be, only quick estimates. You areencouraged to create an account and submit an application to see what your actual costs andoptions are.

FAQ 3. When can I select my health plan?

o Answer: You can select an insurance plan after you have completed an eligibility application andreceived eligibility results indicating that you are eligible to enroll in a Marketplace health planduring the Marketplace Open Enrollment or an SEP if you are eligible.

FAQ 4. Can I select more than one health plan?

o Answer: You can only select one health plan for each individual, and you can select a stand-alone dental plan, if desired and available. You can also select different health plans for differentpeople on a single application by creating different enrollment groups in the enrollment sectionof HealthCare.gov after submitting your application.

FAQ 5. Can I select a stand-alone dental plan?

o Answer: Yes, you can select a stand-alone dental plan, and/or you can select a health plan thatincludes dental coverage. You must be enrolled in a Marketplace health plan to enroll in a stand-alone dental plan through the Marketplace.

FAQ 6. Can I select a child-only health plan?

o Answer: Yes, you can enroll a child in a child-only plan without enrolling yourself in coverage,but you must include yourself and all other members of your tax household on your application(and indicate these members don’t need coverage) if you select that you want to apply for helppaying for coverage.

FAQ 7. After I determine the filtering options for my plan comparison, how do I prioritize them?

o Answer: You will need to determine what factors are most important to you. Some factors thatyou may want to consider include costs, providers (like doctors, hospitals, and pharmacies) thatthe health plan has contracted with to provide health care services (known as the “network”),and what prescription drugs the plan covers (including whether brand or generic versions arecovered).

FAQ 8. Who decides which health plans are available on the Marketplace?

o Answer: Issuers of plans apply to the Marketplace, and the Marketplace, with involvement fromsome states, reviews and certifies health and dental plans that are offered each year.

https://www.healthcare.gov/

https://www.healthcare.gov/see-plans/#/



FAQ 9. When do I view the costs of the health plans?

o Answer: You can view estimated costs of health plans before you apply. If you are determinedeligible to enroll in a Marketplace health plan and for help paying for coverage, you will be ableto view your exact plan costs, taking into account any APTC or CSRs for which you qualify andthe amount of APTC you choose to apply to reduce your monthly premiums.

FAQ 10. Are all Marketplace health plan benefits the same despite different plan costs?

o Answer: No. You will find differences within coverage categories and you may find additionalbenefits that only some plans offer. However, all Marketplace health plans provide coverage ofthe required EHB, and all Marketplace health plans (other than stand-alone dental plan QHPs)are considered minimum essential coverage. HealthCare.gov offers several different features tohelp consumers compare plans, including filtering and sorting options, yearly cost estimates,and in-network provider and medication coverage look-ups.



Appendix B: Support Resources

If consumers require assistance that is outside of assister activities, refer to other organizations and resources as appropriate. Exhibit 13 provides a list of external resources.

Exhibit 13 – External Resources

Resource Contact Information What does this resource do? How should consumers use this resource?

Marketplace Call Center

1-800-318-2596TTY: 1-855-889-4325(all languagesavailable)

The Marketplace Call Center provides assistance to consumers who need information or want to enroll in health coverage through an FFM.

• To get answers toquestions while applying for health coverage using the online or paper application.

• To apply for healthcoverage over the phone.

HealthCare.gov HealthCare.gov This website allows consumers to learn about Marketplace coverage and other coverage programs such as Medicaid and CHIP and enables consumers to apply for and enroll in Marketplace health coverage.

• To find out about healthcoverage options availablein their state.

• To apply for healthcoverage online.

Medicaid Medicaid.gov This state-administered health insurance program is for low-income families and children, pregnant women, the elderly, people with disabilities, and, in many states, other adults. States also have choices in how they design their program, so Medicaid varies state by state and may have a different name in your state.

• To find answers toquestions about health coverage through Medicaid or CHIP.

• To get further informationabout their state’sMedicaid program andagency contactinformation.HealthCare.gov alsoprovides links andresources to Medicaid andCHIP agencies forconsumers if needed.

https://www.healthcare.gov/

https://www.medicaid.gov/

standard operating procedures manual 8 - compare, save

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